Investigation and Results
In February 2021, GDPH identified three HIV clusters among Hispanic MSM using molecular analysis of HIV-1 nucleotide sequence data collected through routine surveillance (1). In Georgia, clusters are derived using a genetic distance threshold of 0.005 nucleotide substitutions per locus in individuals with HIV infection diagnosed within the past 3 years, where priority clusters are defined as those comprising four or more diagnoses in the past 12 months . This definition is consistent with evidence of rapid HIV transmission (1,3). These were the first priority clusters in Georgia, comprising ≥ 40% Hispanics. GDPH analysis of HIV surveillance data showed that HIV diagnoses among Hispanic adolescents and adults in four metro Atlanta boroughs increased from 38.9 to 47.1 per 100,000 people over the period 2014-2019.
After demonstrating the continued growth of the clusters into early 2021, GDPH reviewed partner services’ interview data and attempted to directly reach all individuals in the clusters, including those previously interviewed. However, response was limited, due in part to immigration and deportation-related concerns and a limited number of bilingual staff.
In October 2021, the CDC began providing remote assistance in analyzing epidemiological data for investigative activities, and the GDPH initiated reviewing the medical records of individuals in clusters. Of 38 people with available horoscopes, 10 (26%) spoke primarily Spanish and 12 (32%) were from Latin American countries; five (13%) had mental health diagnoses including depression, anxiety, or bipolar disorder.
In February 2022, GDPH requested CDC assistance in conducting a qualitative assessment with members of the Hispanic MSM community and service providers to identify barriers to accessing medical and social services and HIV care and to facilitate the synthesis and visualization of cluster data . CDC provided support from March to July 2022. This activity was reviewed by CDC and conducted in accordance with applicable federal law and CDC policy.§
By June 30, 2022, GDPH discovered two additional clusters that comprised ≥40% Hispanics, with additional individuals identified among all clusters throughout the study period (Figure). The five clusters included 75 people living with HIV, with clusters ranging in size from four to 45 people. The mean age of individuals in clusters was 29 years (range = 16–54 years), 56% were identified as Hispanic, 96% were assigned male gender at birth, and 81% reported male-to-male sexual contact (Table). Overall, 84% of individuals lived in one of Atlanta’s four metropolitan areas. 40% of diagnoses were from facilities with infectious disease providers specializing in HIV care, 27% in primary care or emergency care facilities, 13% in inpatient facilities or emergency departments, and 11% in public health departments. 85% of individuals in these clusters were virally suppressed¶; however, new diagnoses continued to be identified throughout the investigation (Figure).
As of June 30, 2022, of 52 individuals in clusters who were eligible for interviews with partner services**, 34 (65%) had been interviewed, 16 (31%) could not be reached, and two (4%) declined. Of those surveyed, 20 (59%) said they had met partners online, and four (12%) said they had ever taken HIV pre-exposure prophylaxis (PrEP).
CDC and Department of Health officials conducted qualitative interviews with 28 Hispanic MSM and one transgender woman in the four counties and 28 individual or group interviews with 65 medical and social providers who treated individuals in groups or served Hispanic MSM. Community members were recruited through vendor referrals, social media, and in bars and clubs. Since several attempts have already been made to reach people in clusters for partner service interviews, further attempts to conduct qualitative interviews with people in clusters were not made.
Interviewed participants identified barriers to accessing medical and social services, including few Spanish-speaking staff, limited Spanish-language materials, and fear of deportation and other immigration-related concerns. Participants also reported barriers to accessing HIV prevention and care, including stigma of MSM and PLHIV due to sex-related cultural norms, low awareness of HIV and other sexually transmitted infections due to limited access to primary care and limited HIV delivery -Primary and emergency care services and limited outreach and marketing to the Hispanic MSM community.